Transcript Slide 1

ASC QUALITY
REPORTING
Current Procedural Terminology © 2012 American Medical Association.
All Rights Reserved.
TODAY’S PRESENTER
Paul Cadorette CPC, CPC-H, CPC-P, COSC, CASC
Director of Education – [email protected]
Paul has achieved his core credentials in
Physician, Hospital, and Payor classifications
from the American Academy of Professional
Coders along with specialty credentials certifying
his expertise in Orthopedic and ASC coding.
Current Procedural Terminology © 2012 American Medical Association.
All Rights Reserved.
Use of this handout is for informational
purposes only – Confirm Carrier/Corporate
policies before billing any services
Current Procedural Terminology © 2012 American Medical Association.
All Rights Reserved.
October 1, 2012: ASC’s will be required to report on 5 quality measures
Additional measures to be added in 2013 and 2014
Failure to report will result in 2% payment reduction for Medicare claims submitted in 2014
Current Procedural Terminology © 2012 American Medical Association.
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Benchmark
• Minimum requirement 50% of relevant claims where Medicare is
the primary payer - (2012 & 2013)
• Threshold will be increased in future years
• Currently, payment is for reporting
• Payment for performance may be considered at a later date
October 1 – December 31, 2012:
• ASCs will be considered successful reporters and not face future financial
penalties if 50 percent of their Medicare claims contain quality data codes.
(This percentage may increase in future years.) In addition, ASCs should
include the G-codes only on claims where Medicare is the primary payer
January 1, 2013:
• ASCs should begin placing the G-codes on claims where Medicare is either
the primary or secondary payer
Current Procedural Terminology © 2012 American Medical Association.
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Medicare Secondary Payer
• While the change request for the carriers was released making the
codes available for use April 1, 2012, CMS releases a tape for the
private insurers once per year only.
• CMS will release an updated tape in October/November of 2012 that
will be active beginning January 1, 2013.
•
•
ASC quality reporting G-codes are effective April 1, 2012 for Medicare carriers
Private insurers will not have this information for use until January 1, 2013.
• Private insurers will reject claims with the G-codes. Therefore, you
should use these codes only for Medicare paid claims where
Medicare is the primary payer. Where there is a secondary payer,
the cross-over contractor should be handling the removal of the
codes before forwarding, but CMS will be monitoring the situation.
Current Procedural Terminology © 2012 American Medical Association.
All Rights Reserved.
Current Procedural Terminology © 2012 American Medical Association.
All Rights Reserved.
Use of Fall/Burn Measures
• Admission: completion of registration upon
entry into the facility
• Discharge: occurs when the patient leaves the
confines of the ASC
• Patient fall in the parking lot (not reported)
• Coffee spilled on patient causing burn (reported)
• Patient is discharged from ASC and is immediately
taken to hospital in private vehicle/car (reported)
Current Procedural Terminology © 2012 American Medical Association.
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Reporting IV Antibiotic Timing
• On time antibiotic infusion: initiated within one hour prior
to the time of the initial surgical incision or the beginning
of the procedure, or two hours prior if vancomycin or
fluoroquinolones are administered
The following antibiotics are considered prophylaxis for surgical site infections
• Ampicillin/sulbactam, Aztreonam, Cefazolin,
Cefmetazole, Cefotetan, Cefoxitin, Cefuroxime,
Ciprofloxacin, Clindamycin, Ertapenem, Erythromycin,
Gatifloxacin, Gentamicin, Levofloxacin, Metronidazole,
Moxifloxacin, Neomycin and Vancomycin
Current Procedural Terminology © 2012 American Medical Association.
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Frequently Asked Questions
• Nurses routinely document
what happened, not what didn't
happen. If there's a patient
burn, it's documented; if not,
nothing is mentioned in the
chart. In order to use the QDC
codes, is this documentation
required?
• Documentation of non-events is
not required. However, if your
coding department is requiring
such documentation, you may
develop a tool that allows you to
document the information
Current Procedural Terminology © 2012 American Medical Association.
All Rights Reserved.
Where are the G Codes reported on the claim form?
•
Quality-data codes (QDC) must be entered on the Form CMS-1500 and
have an associated charge in order to be accepted into the CMS
warehouse. These codes will populate Fields 24D and 24F on the Form
CMS-1500.
•
The submitted charge field cannot be blank.
•
The line-item charge should be the numeral "0" (zero). Please note that
dollar signs ($) or decimal points are not accepted.
•
If a system does not allow a zero line-item charge, a nominal amount can
be substituted; the beneficiary is not liable for this nominal amount.
•
Entire claims with a zero charge will be rejected. The total charge for the
claim cannot be zero.
•
When a zero charge or a nominal amount is submitted to the carrier or
contractor, payment for the amount included in the ASC QDC line is denied
and tracked.
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All Rights Reserved.
Where are the G Codes reported on the claim form?
211.3
45385
1200 00
G8907
0
G8918
0
211.3
E870.4
998.2
E849.7
45385
G8909
G8911
G8913
G8914
G8918
Current Procedural Terminology © 2012 American Medical Association.
All Rights Reserved.
These answers are based on guidance issued by CMS for the Physician Quality
Reporting System (PQRS) program. While we anticipate that the agency will apply similar
guidance to the ASC Quality Reporting Program (QRP), CMS could apply different
standards. These FAQs will be updated when final guidance is issued by CMS.
Will my ASC receive a Remittance Advice (RA) associated with a claim that contains a G-code line-item?
•
ASCs will receive an RA for a claim on which the G-code is reported. The RA will include a standard remark
code (N365) and a message confirming that the G-code passed into the National Claims History (NCH) file.
N365 - “This procedure code is not payable. It is for reporting/information purposes only.” The N365 remark
code does not indicate whether the G-code is accurate for that claim or for the measure being reported.*
•
ASCs should keep track of all cases that they report using a G-code so that they can verify the G-codes that
their ASC reported against the RA notice sent by their Medicare Administrative Contractor (MAC). Each Gcode line-item will be listed with the N365 denial remark code.
•
ASCs should note that the submission of a non-zero charge amount for G-codes may complicate secondary
payers’ processing of the claims. ASCs are not allowed to collect any monies from beneficiaries for charges
submitted for the G-codes.
We forgot to put the G-codes on a claim. Can we resubmit the claim with the proper G-codes attached?
•
Claims may not be resubmitted for the sole purpose of adding or correcting G-codes.*
We submitted a claim that was denied, but the error has been corrected and we plan to resubmit the
claim. Do we include the G-codes again?
•
If a denied claim is subsequently corrected through the appeals process involving the carrier/Medicare
Administrative Contractors, G-codes should also be included on the resubmitted claim in accordance with the
instructions in the measure specifications.*
Current Procedural Terminology © 2012 American Medical Association.
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Non “G” Code Reporting
July 1 – August 15, 2013: ASC’s will be required to report:
• Whether they used a safe surgery checklist at any time between
January 1, 2012, and December 31, 2012
• Starting Jan. 2013, SSCL must be used for the entire year
No particular checklist is required. For a list of sample safe surgery checklists, visit
ascassociation.org/QualityReporting
• The total Surgical Care Volume for selected groups of procedures
•
In 2014, one additional measure will be added to the list of quality reporting
measures, Influenza Vaccination Coverage Among Health Care Personnel. This
measure assesses the percentage of health care personnel who have been
immunized for influenza during the flu season (October 1, 2014 – March 31, 2015)
These measures are not patient-specific. They apply to the general operation of the ASC.
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http://www.who.int/patientsafety/safesurgery/en/
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http://www.aorn.org/uploadedimages/Images/Images/comprehensive_surgical_checklist_RGB961.jpg
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http://www.asge.org/WorkArea/showcontent.aspx?id=14262
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Frequently Asked Questions
• Does the Safe Surgery Checklist need to be a paper document
or can it be a process? Can there be just a checkbox that states
safe surgery checklist completed?
• The CMS ASC Quality Reporting Program Quality Measures
Specifications Manual on page 19 states:
• The use of a Safe Surgery Checklist for surgical procedures that
includes safe surgery practices during each of the three critical
perioperative periods: the period prior to the administration of
anesthesia, the period prior to skin incision, and the period of
closure of incision and prior to the patient leaving the operating
room.
• CMS does not state any requirement for documentation at the
patient level. This is the decision of the facility.
Current Procedural Terminology © 2012 American Medical Association.
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ASCs will be required to report their total surgical volume for certain
specified procedures performed Jan.1 - Dec. 31, 2012 for all patients
(Medicare and non-Medicare) in 1 of the 9 categories listed below
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Current Procedural Terminology © 2012 American Medical Association.
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Reporting
Outcome Measures
• 5 Quality measures (G8907-G8918) are reported on Medicare Claim
Forms (CMS-1500)
Structural Measures – www.qualitynet.org
• Safe Surgery Checklist Use
• ASC Volume of Selected Procedures
• Influenza Vaccination Coverage Among Health Care Workers
www.cdc.gov/nhsn/index.html - (HCP definitions pending)
• Staff on facility payroll
• Licensed practitioners (Physicians, APN’s and PA’s)
• Students and volunteers
• Still to be determined – Vendors
Current Procedural Terminology © 2012 American Medical Association.
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How to Prepare Your ASC
• Communicate the upcoming changes to your staff
(clinical and business) and physicians
• How will data collection be performed and processed by the
billing department
• Designate a responsible staff member
• Facility will need a Quality Net administrator
• Establishing and maintaining account
• Reviewing and communicating updates/changes
(every 6 months)
• Review specifications of measures
• Staff (clinical and business) training
• Begin the process of collecting data
Current Procedural Terminology © 2012 American Medical Association.
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Quality Net Reporting
• ASCs will be required to designate an individual to
serve as the Center’s QualityNet administrator (no later than Aug. 15, 2013)• ASCs should allow two weeks to complete the
process of registering a QualityNet administrator
with CMS
• Because these accounts are deactivated after
120 days of inactivity, it is recommended that
ASCs wait until mid March 2013 to register
Current Procedural Terminology © 2012 American Medical Association.
All Rights Reserved.
REVIEW OF LESIONS
INTEGUMENTARY CODING
Current Procedural Terminology © 2012 American Medical Association.
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Adjacent Tissue Transfer
4cm
Primary Defect
Primary defect: 2cm x 2cm = 4sq cm
Secondary defect: 4cm x 2cm = 8sq cm
Total Size: 4sq cm + 8sq cm = 12sq cm
2cm
2cm
Add the sizes of both secondary
defects to the primary defect to
determine the proper CPT code
2cm
Secondary defect
Advancement flaps
Secondary defect
Primary defect
Current Procedural Terminology © 2012 American Medical Association.
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Undermining alone of adjacent tissues to achieve closure,
without additional incisions does not constitute adjacent
tissue transfer; see complex repair codes 13100-13160
Wide excision of scalp angiosarcoma with adjacent tissue transfer
An ellipse was fashioned around the previous biopsy site which measured
5cm by 3cm. Dissection was made down to temporalis fascia which was left
undisturbed and the mass was submitted to pathology. The edges were widely
undermined, advanced toward each other and reapproximated.
Attention was then turned to the foot where the lesion on the lateral aspect of the
dorsum was excised with the #15 blade. The margins were undermined and
flaps were advanced. Closure was carried out with 5-0 Vicryl and interrupted 6-0
nylon vertical mattress sutures.
Advancement flaps
Undermining
Current Procedural Terminology © 2012 American Medical Association.
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Documentation
Do not add the total length and then multiply by the largest width
7x4 and 7x5 14 x 5 = 70sq cm or 14 x 9 = 126sq cm
2x2 and 2x3 = 10sq cm
4x3 = 12sq cm or 4x5 = 20sq cm
14301 – Adjacent tissue transfer or rearrangement, any area; defect 30.1 to 60.0sq cm
14302 – each additional 30.0 sq cm or part thereof
Current Procedural Terminology © 2011 American Medical Association.
All Rights Reserved.
Adjacent Tissue Transfer
Question: When you have 2 lesions from the same
anatomical area (trunk) and separate adjacent tissue
transfer procedures are performed for each defect how is
this reported?
Answer: You would report one CPT code for each tissue
transfer procedure as long as the margins were separate
and not contiguous.
Do not add the sizes together and report one CPT code
(Loss of Revenue)
CPT ASSISTANT JUL: 00
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Intermediate Repair (Closure)
•
The "deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia" referred to in the CPT definition of intermediate repair
refers to subcutaneous tissue that is deeper than the dermis rather
than to the deep subcutaneous tissue.
•
In summary, wounds that require closure of subcutaneous tissue or
more than one layer of tissue beneath the dermis should be coded as
intermediate repairs, unless the criteria for a complex closure are met.
CPT ASSISTANT AUG. 06
Current Procedural Terminology © 2011 American Medical Association.
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Tumor vs. Lesion Coding
• DIGITAL TUMORS – (fingers/toes) – subfascial is
defined as those tumors involving the tendons, tendon
sheaths or joints of the digit. Tumors which simply abut
but do not breach the tendon, tendon sheath, or joint
capsule are considered subcutaneous soft tissue tumors
Do not use tumor codes when a CPT code exists for
“Excision of lesion of tendon sheath or joint capsule (cyst
or ganglion)”
• Hands/Fingers and Foot/toes
• Less than 1.5cm - 1.5cm or greater
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Tumor vs. Lesion Coding
• Question: What is the appropriate code to report for
excision of epidermal or pilar cyst?
• Answer: Excision of epidermal or pilar cysts are
properly coded with the integumentary excision
codes, together with an intermediate repair code “when
indicated”. Because they originate from the dermis or
adnexal structures, they are not soft tissue tumors, even
though they may protrude into the subcutaneous tissue.
JUL. 10 CPT Assistant
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Tumor Code Guidelines
• Additionally report “appreciable” vessel exploration
and/or neuroplasty
(APPRECIABLE – sufficient to be easily seen, measured or noticed)
• Tumor size – greatest diameter + most narrow margins
(same as lesion coding)
• Simple and Intermediate repairs are included in the
tumor excision codes
• Complex repair, flaps and grafts are additionally
reported
Current Procedural Terminology © 2011 American Medical Association.
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Repair/Closure Guidelines
• Simple repair is included in the lesion excision
• Add the lengths of repairs…..
• That are in the same classification (simple/int/complex)
• That are grouped in the same CPT code descriptor
(Intermediate repair of 5cm scalp wound and 12cm trunk
wound – Report 17cm wound closure)
• List repairs by order of complexity
• Complex (1st), Intermediate (2nd), Simple (3rd)
Current Procedural Terminology © 2011 American Medical Association.
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Repair/Closure Guidelines
• Debridement is only reported when “appreciable
amounts of contaminated tissue are removed or
when debridement is the only procedure
performed without closure”
• Repair of injuries to tendons, nerves or blood
vessels are reported with a CPT code from the
anatomical section – repair then becomes
inclusive unless complex
CPT MANUAL INSTRUCTIONS
Current Procedural Terminology © 2011 American Medical Association.
All Rights Reserved.
Surgical Preparation
• Codes 15002-15005 “describe the services
related to preparing a clean and viable wound
surface”
• Application of grafts include simple debridement
of granulation tissue or recent avulsions
(tangential – lightly touched, of no consequence)
• Complex repair, adjacent tissue transfer, flaps,
grafts, skin replacements, and skin substitutes
are reported separately
Current Procedural Terminology © 2011 American Medical Association.
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Surgical Preparation
• Example 1
• Example 2
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Graft Preparation
• Graft preparation includes simple debridement
of granulation tissue or recent avulsion
• “Excision” of open wound, burn eschar, or scar
• “Incisional” release of scar contracture
• Using a sharp #15 scalpel blade and forceps, an incision
was made and the wound was ellipsed including a
margin of normal tissue that measured approx. 9 cm in
length and 3 cm wide.
Current Procedural Terminology © 2011 American Medical Association.
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“or part thereof”
• FTSG trunk - 6cm x 7cm = 42sq cm
• Report 15200 for the first 20sq cm
• Report 15201 for an additional 20sq cm
• Report 15201 for the last 2sq cm since it is part of
an additional 20sq cm
20 + 20 + 2 = 42
Current Procedural Terminology © 2011 American Medical Association.
All Rights Reserved.
Multiple Skin Grafts
Question: A 3sq cm FTSG was placed on the
cheek, chin and a finger. Since this was 3
separate anatomical areas would 15240 be
reported 3 times?
Answer: No, since cheek, chin and fingers are all
identified by the same full thickness graft code
and the total area covered was 9sq cm CPT
code 15240 would only be reported one time
CPT ASSISTANT NOV: 00
Current Procedural Terminology © 2011 American Medical Association.
All Rights Reserved.
Modifier Usage
• Do not use a modifier if the definition of a
CPT code is used for multiple body parts
CPT ASSISTANT MAY: 03
FOR EXAMPLE
• Excision of lesion trunk, arms, legs
• Excision of lesion face, ear, eyelid, nose, lip
• Modifier 59 may be need when multiple lesions
are excised (Specific carrier guidelines)
Current Procedural Terminology © 2011 American Medical Association.
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CEU’s
• Go to www.mdstrategies.com and select the TRAINING tab.
• Login using your email address and password. If you have forgotten
or did not receive your password, use the “Forgot Password” link.
Attendance CEU
• Complete the “Post Webinar Exam” for the Attendance CEU
Supplemental CEU
• Complete the “Supplemental CEU Exam” for additional CEU credit
• If you have any questions or problems, please email
[email protected].
Current Procedural Terminology © 2012 American Medical Association.
All Rights Reserved.